THE ORIENTAL INSURANCE COMPANY LIMITED

Regd.Office: Oriental House,P.B.No.7037,A-25/27,Asaf Ali Road, New Delhi-110 002

CIN No. U66010DL1947GOI007158

CORONA KAVACH POLICY- ORIENTAL INSURANCE

POLICY DOCUMENT

1. PREAMBLE

This Policy is a contract of insurance issued by The Oriental Insurance Company Limited
(hereinafter called the ‘Company’) to the proposer mentioned in the schedule (hereinafter
called the ‘Insured’) to cover the person(s) named in the schedule (hereinafter called the
‘Insured Persons’). The policy is based on the statements and declaration provided in the
proposal Form by the proposer and is subject to receipt of the requisite premium.

2. OPERATIVE CLAUSE

If during the policy period one or more Insured Person (s) is required to be hospitalized for
treatment of Covid at a Hospital or given Home Care Treatment following Medical Advice of
a duly qualified Medical Practitioner, the Company shall indemnify medically necessary
expenses towards the Coverage mentioned in the policy schedule.

Provided further that, any amount payable under the policy shall be subject to the terms of
coverage exclusions, conditions and definitions contained herein. Maximum liability of the
Company under all such Claims during the Policy Period shall be the Sum Insured (Individual
or Floater) opted and specified in the Schedule.

3. DEFINITIONS
The terms defined below and at other junctures in the Policy have the meanings ascribed to
them wherever they appear in this Policy and, where, the context so requires, references to the
singular include references to the plural; references to the male includes the female and
references to any statutory enactment includes subsequent changes to the same.

3.1.Age means age of the Insured person on last birthday as on date of commencement of the
Policy.

3.2.AYUSH Treatment refers to hospitalization treatments given under Ayurveda, Yoga and
Naturopathy, Unani, Siddha and Homeopathy systems.

3.3.An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical

treatment procedures and interventions are carried out by AYUSH Medical Practitioner(s)
comprising of any of the following:
a. Central or State Government AYUSH Hospital or
b. Teaching hospital attached to AYUSH College recognized by the Central
Government/Central Council of Indian Medicine/Central Council for Homeopathy; or
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any
recognized system of medicine, registered with the local authorities, wherever
applicable, and is under the supervision of a qualified registered AYUSH Medical
Practitioner and must comply with all the following criterion:
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 i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped
operation theatre where surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the
insurance company’s authorized representative.

3.4.Cashless Facility means a facility extended by the insurer to the insured where the
payments, of the costs of treatment undergone by the insured person in accordance with
the Policy terms and conditions, are directly made to the network provider by the insurer
to the extent pre-authorization is approved.

3.5.Condition Precedent means a Policy term or condition upon which the Company’s
liability under the Policy is conditional upon.

3.6.COVID: For the purpose of this Policy, Coronavirus Disease means COVID-19 as
defined by the World Health Organization (WHO) and caused by the virus SARS-CoV2.

3.7.Day Care Treatment means medical treatment, and/or surgical procedure which is:
i. undertaken under general or local anesthesia in a hospital/day care centre in less than
twenty-four hours because of technological advancement, and
ii. which would have otherwise required a hospitalization of more than twenty-four hours.
iii. Treatment normally taken on an out-patient basis is not included in the scope of this
definition.

3.8.Disclosure to information norm: The policy shall be void and all premiums paid thereon
shall be forfeited to the Company in the event of misrepresentation, mis-description or
non-disclosure of any material fact by the policyholder.

3.9.Emergency Care: Emergency care means management for an illness or injury which
results in symptoms which occur suddenly and unexpectedly, and requires immediate care
by a medical practitioner to prevent death or serious long term impairment of the insured
person’s health.

3.10. Family means, the Family that consists of the proposer and any one or more of the family
members as mentioned below:
i. Legally wedded spouse.
ii. Parents and Parents-in-law.
iii.Dependent Children (i.e. natural or legally adopted) between the day 1 of age to 25 years. If
the child above 18 years of age is financially independent, he or she shall be ineligible for
coverage

3.11. Health care worker for the purpose of this policy shall mean doctors, nurses,
midwives, dental practitioners and other health professionals including laboratory
assistants, pharmacists, physiotherapists, technicians and people working in hospitals.

3.12. Home Care Treatment means treatment availed by the Insured Person at home for
Covid on positive diagnosis of Covid in a Government authorized diagnostic Centre,
which in normal course would require care and treatment at a hospital but is actually
taken at home provided that:
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 a) The Medical practitioner advices the Insured person to undergo treatment at home.
b) There is a continuous active line of treatment with monitoring of the health status
by a medical practitioner for each day through the duration of the home care
treatment.
c) Daily monitoring chart including records of treatment administered duly signed by
the treating doctor is maintained.

3.13. Hospital means any institution established for in-patient care and day care treatment of
disease/ injuries and which has been registered as a hospital with the local authorities
under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the
enactments specified under Schedule of Section 56(1) of the said Act, OR complies
with all minimum criteria as under:
i. has qualified nursing staff under its employment round the clock;
ii. has at least ten inpatient beds, in those towns having a population of less than ten lakhs and
fifteen inpatient beds in all other places;
iii. has qualified medical practitioner (s) in charge round the clock;
iv. has a fully equipped operation theatre of its own where surgical procedures are carried out
v. maintains daily records of patients and shall make these accessible to the Company’s
authorized personnel.

For the purpose of this policy any other set-up designated by the Government as hospital for
the treatment of Covid shall also be considered as hospital.

3.14. Hospitalization means admission in a hospital for a minimum period of twenty-four

(24) hours consecutive ‘In-patient care’ provided it will not include procedures/
treatments, where such admission could be for a period of less than twenty-four (24)
consecutive hours.

3.15. In-Patient Care means treatment for which the insured person has to stay in a hospital
for more than 24 hours for a covered event.

3.16. Insured Person means person(s) named in the schedule of the Policy.

3.17. Intensive Care Unit means an identified section, ward or wing of a hospital which is
under the constant supervision of a dedicated medical practitioner(s), and which is
specially equipped for the continuous monitoring and treatment of patients who are in a
critical condition, or require life support facilities and where the level of care and
supervision is considerably more sophisticated and intensive than in the ordinary and
other wards.

3.18. ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards
ICU expenses on a per day basis which shall include the expenses for ICU bed, general
medical support services provided to any ICU patient including monitoring devices,
critical care nursing and intensivist charges.

3.19. Medical Advice means any consultation or advice from a Medical Practitioner
including the issue of any prescription or follow up prescription.

3.20. Medical Expenses means those expenses that an insured person has necessarily and
actually incurred for medical treatment on account of illness or accident on the advice of a
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 medical practitioner, as long as these are no more than would have been payable if the
insured person had not been insured and no more than other hospitals or doctors in the
same locality would have charged for the same medical treatment.

3.21. Medical Practitioner means a person who holds a valid registration from the Medical
Council of any state or Medical Council of India or Council for Indian Medicine or for
Homeopathy set up by the Government of India or a State Government and is thereby
entitled to practice medicine within its jurisdiction; and is acting within the scope and
jurisdiction of the licence.

3.22. Medically Necessary Treatment means any treatment, tests, medication, or stay in
hospital or part of a stay in hospital which
i. is required for the medical management of illness or injury suffered by the
insured;
ii. must not exceed the level of care necessary to provide safe, adequate and
appropriate medical care in scope, duration, or intensity;
iii. must have been prescribed by a medical practitioner;
iv. must conform to the professional standards widely accepted in international
medical practice or by the medical community in India.

3.23. Network Provider means hospitals enlisted by insurer, TPA or jointly by an insurer
and TPA to provide medical services to an insured by a cashless facility.

3.24. Non- Network Provider means any hospital that is not part of the network.

3.25. Notification of Claim means the process of intimating a claim to the Insurer or TPA
through any of the recognized modes of communication.

3.26. Out-Patient (OPD) Treatment means treatment in which the insured visits a clinic /
hospital or associated facility like a consultation room for diagnosis and treatment based
on the advice of a medical practitioner. The insured is not admitted as a day care or in-
patient

3.27. Pre-hospitalization Medical Expenses means medical expenses incurred during the
period of 15 days preceding the hospitalization/home care treatment of the Insured
Person, provided that:

i. Such Medical Expenses are incurred for the same condition for which the
Insured Person’s Hospitalization//home care treatment was required, and
ii. The In-patient Hospitalization claim//home care treatment claim for such
hospitalization/home care treatment is admissible by the Insurance Company.

3.28. Post-hospitalization Medical Expenses means medical expenses incurred during the
period of 30 days immediately after the insured person is discharged from the hospital/
completion of home care treatment provided that:

i. Such Medical Expenses are for the same condition for which the insured
person’s hospitalization/home care treatment was required, and
ii. The inpatient hospitalization/home care treatment claim for such
hospitalization/home care treatment is admissible by the Insurance Company.

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3.29. Policy means these Policy wordings, the Policy Schedule and any applicable
endorsements or extensions attaching to or forming part thereof. The Policy contains
details of the extent of cover available to the Insured person, what is excluded from the
cover and the terms & conditions on which the Policy is issued to the Insured person.

3.30. Policy period means period of three and half months (3 ½ months), six and half months
(6 ½ months), nine and half months (9 ½ months) as mentioned in the schedule for which
the Policy is issued.

3.31. Policy Schedule means the Policy Schedule attached to and forming part of Policy

3.32. Qualified Nurse means a person who holds a valid registration from the Nursing
Council of India or the Nursing Council of any state in India.

3.33. Room Rent means the amount charged by a hospital towards Room and Boarding
expenses and shall include the associated medical expenses.

3.34. Sub-limit means a cost sharing requirement under a health insurance policy in which an
insurer would not be liable to pay any amount in excess of the pre-defined limit

3.35. Sum Insured means the pre-defined limit specified in the Policy Schedule. Sum
Insured represents the maximum, total and cumulative liability for any and all claims
made under the Policy, in respect of that Insured Person (on Individual basis) or all
Insured Persons (on Floater basis) during the Policy Period.

3.36. Surgery or Surgical Procedure means manual and / or operative procedure (s)
required for treatment of an illness or injury, correction of deformities and defects,
diagnosis and cure of diseases, relief of suffering and prolongation of life, performed in a
hospital or day care centre by a medical practitioner.

3.37. Third Party Administrator (TPA) means a Company registered with the Authority,
and engaged by an insurer, for a fee or by whatever name called and as may be mentioned
in the health services agreement, for providing health services.

3.38. Waiting Period means a period from the inception of this Policy during which Covid is
not covered.

4. Base Cover:

The cover listed below is in-built Policy benefit and shall be available to all Insured Persons in
accordance with the procedures set out in this Policy.

4.1.Covid Hospitalization Cover

The Company shall indemnify medical expenses incurred for Hospitalization of the Insured
Person during the Policy period for the treatment of Covid on Positive diagnosis of Covid in a
government authorized diagnostic centre including the expenses incurred on treatment of any
comorbidity along with the treatment for Covid up to the Sum Insured specified in the policy
schedule, for,
i. Room Rent, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home.

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ii. Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses.
iii. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid
directly to the treating doctor / surgeon or to the hospital
iv. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, ventilator
charges, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities,
PPE Kit, gloves, mask and such similar other expenses.
v. Road Ambulance subject to a maximum of Rs.2000/- per hospitalization for the Ambulance
services offered by a Hospital or by an Ambulance service provider, provided that the
Ambulance is availed only in relation to Covid Hospitalization for which the Company has
accepted a claim under section This also includes the cost of the transportation of the
Insured Person from a Hospital to the another Hospital as prescribed by a Medical
Practitioner.
Note:
1. Expenses of Hospitalization for a minimum period of 24 consecutive hours only shall be
admissible.

4.2 Home Care Treatment Expenses:

Home Care Treatment means Treatment availed by the Insured Person at home for Covid on
positive diagnosis of Covid in a Government authorized diagnostic Centre, which in normal
course would require care and treatment at a hospital but is actually taken at home maximum
up to 14 days per incident provided that:

a) The Medical practitioner advices the Insured person to undergo treatment at home.
b) There is a continuous active line of treatment with monitoring of the health status by a
medical practitioner for each day through the duration of the home care treatment.
c) Daily monitoring chart including records of treatment administered duly signed by the
treating doctor is maintained.
d) Insured shall be permitted to avail the services as prescribed by the medical practitioner.
Cashless or reimbursement facility shall be offered under homecare expenses subject to
claim settlement policy disclosed in the website.
e) In case the insured intends to avail the services of non-network provider claim shall be
subject to reimbursement, a prior approval from the Insurer needs to be taken before
availing such services.

In this benefit, the following shall be covered if prescribed by the treating medical practitioner
and is related to treatment of COVID,
a. Diagnostic tests undergone at home or at diagnostics centre
b. Medicines prescribed in writing
c. Consultation charges of the medical practitioner
d. Nursing charges related to medical staff
e. Medical procedures limited to parenteral administration of medicines
f. Cost of Pulse Oximeter, Oxygen cylinder and Nebulizer

4.3 AYUSH Treatment

The Company shall indemnify medical expenses incurred for inpatient care treatment for Covid
on Positive diagnosis of COVID test in a government authorized diagnostic centre including
the expenses incurred on treatment of any comorbidity along with the treatment for Covid
under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems of medicines

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during the Policy Period up to the limit of sum insured as specified in the policy schedule in
any AYUSH Hospital.

Covered expenses shall be as specified under Covid Hospitalization Expenses (Section 4.1)

4.4 Pre Hospitalization

The company shall indemnify pre-hospitalization/home care treatment medical expenses

incurred, related to an admissible hospitalization/home care treatment, for a fixed period of 15
days prior to the date of admissible hospitalization/home care treatment covered under the
policy.

4.5 Post Hospitalization

The company shall indemnify post hospitalization//home care treatment medical expenses
incurred, related to an admissible hospitalization//home care treatment, for a fixed period of
30days from the date of discharge from the hospital, following an admissible hospitalization
covered under the policy.

4.6 The expenses that are not covered in this policy are placed under List-I of Annexure-A. The
list of expenses that are to be subsumed into room charges, or procedure charges or costs of
treatment are placed under List-II, List-III and List-IV of Annexure-A respectively.

5. Optional cover:

The cover listed below is Optional Policy benefit and shall be available to Insured Persons in
accordance with the terms set out in the Policy, if the listed cover is opted

5.1 Hospital Daily Cash: The Company shall pay the Insured Person 0.5% of sum insured per
day for each 24 hours of continuous hospitalization for which the Company has accepted a
claim under Section- 4.1 Hospitalization Cover.

The benefit shall be payable maximum up to 15 days during a policy period in respect of every
insured person.
The total amount payable in respect of Covers 4.1, 4.2, 4.3, 4.4, 4, 4.5, 5.1, shall not exceed
100% of the Sum Insured during a policy period.

6. Waiting Period
The Company shall not be liable to make any payment under the policy in connection with or
in respect of following expenses till the expiry of waiting period mentioned below:

6.1. First Fifteen Days Waiting Period

Expenses related to the treatment of Covid within 15 days from the policy commencement date
shall be excluded.

7. EXCLUSIONS

The Company shall not be liable to make any payment under the policy, in respect of any
expenses incurred in connection with or in respect of:

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 7.1 Investigation & Evaluation (Code- Excl04)

Expenses related to any admission primarily for diagnostics and evaluation purposes.
Any diagnostic expenses which are not related or not incidental to the current diagnosis
and treatment

7.2 Rest Cure, rehabilitation and respite care (Code- Excl05)

Expenses related to any admission primarily for enforced bed rest and not for receiving
treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such as
help with activities of daily living such as bathing, dressing, moving around
either by skilled nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address physical, social,
emotional and spiritual needs.

7.3 Dietary supplements and substances that can be purchased without prescription,
including but not limited to Vitamins, minerals and organic substances unless prescribed
by a medical practitioner as part of hospitalization claim or Home care treatment.

7.4 Unproven Treatments:

Expenses related to any unproven treatment, services and supplies for or in connection with
any treatment. Unproven treatments are treatments, procedures or supplies that lack
significant medical documentation to support their effectiveness. However, treatment
authorized by the government for the treatment of COVID shall be covered.

7.5 Any claim in relation to Covid where it has been diagnosed prior to Policy Start Date.

7.6 Any expenses incurred on Day Care treatment and OPD treatment

7.7 Diagnosis /Treatment outside the geographical limits of India

7.8 Testing done at a Diagnostic centre which is not authorized by the Government shall
not be recognized under this Policy

7.9 All covers under this Policy shall cease if the Insured Person travels to any country
placed under travel restriction by the Government of India.

8. CLAIM PROCEDURE

8.1Procedure for Cashless claims:

(i) Treatment may be taken in a network provider and is subject to pre authorization by the
Company or its authorized TPA. (ii) Cashless request form available with the network provider
and TPA shall be completed and sent to the Company/TPA for authorization. (iii) The
Company/ TPA upon getting cashless request form and related medical information from the
insured person/ network provider will issue pre-authorization letter to the hospital after
verification. (iv) At the time of discharge, the insured person has to verify and sign the
discharge papers, pay for non-medical and inadmissible expenses. (v) The Company / TPA
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reserves the right to deny pre-authorization in case the insured person is unable to provide the
relevant medical details. (vi) In case of denial of cashless access, the insured person may obtain
the treatment as per treating doctor’s advice and submit the claim documents to the Company /
TPA for reimbursement.

8.2 Procedure for reimbursement of claims:

For reimbursement of claims the insured person may submit the necessary documents to TPA
/Company within the prescribed time limit as specified hereunder.

Sl. Type of Claim Prescribed Time limit

No

1. Reimbursement of hospitalization and pre Within thirty days of date of

hospitalization expenses discharge from hospital

2. Reimbursement of post hospitalization Within fifteen days from completion

expenses of post hospitalization treatment

3 Reimbursement of Home Care expenses Within thirty days from completion of

home care treatment

8.3Notification of Claim

Notice with full particulars shall be sent to the Company/TPA (if applicable) as under:
i. Within24hours from the date of emergency hospitalization/cashless home care treatment.
ii. At least 48 hours prior to admission in Hospital in case of a planned Hospitalization.

8.4Documents to be submitted:

The claim is to be supported with the following documents and submitted within the prescribed
time limit.

Benefits Claims Documents Required

1. Covid i. Duly filled and signed Claim Form
Hospitalization ii. Copy of Insured Person’s passport, if available (All pages)
Cover iii. Photo Identity proof of the patient (if insured person does
not own a passport)

iv. Medical practitioner’s prescription advising admission

v. Original bills with itemized break-up
vi. Payment receipts
vii. Discharge summary including complete medical history of
the patient along with other details.

viii. Investigation reports including Insured Person’s test reports

from Authorized diagnostic centre for COVID

ix. OT notes or Surgeon’s certificate giving details of the

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 operation performed, wherever applicable
x. Sticker/Invoice of the Implants, wherever applicable.
xi. NEFT Details (to enable direct credit of claim amount in
bank account) and cancelled cheque
xii. KYC (Identity proof with Address) of the proposer, where
claim liability is above Rs 1 Lakh as per AML Guidelines
xiii. Legal heir/succession certificate, wherever applicable
xiv. Any other relevant document required by Company/TPA
for assessment of the claim.
2. Home Care i. Duly filled and signed Claim Form
treatment ii. Copy of Insured Person’s passport, if available (All
expenses pages)
iii. Photo Identity proof of the patient (if insured person
does not own a passport)
iv. Medical practitioners’ prescription advising
hospitalization
v. A certificate from medical practitioner advising
treatment at home or consent from the insured person on
availing home care benefit.
vi. Discharge Certificate from medical practitioner
specifying date of start and completion of home care
treatment.
vii. Daily monitoring chart including records of treatment
administered duly signed by the treating doctor is
maintained.

Note:
1. The company shall only accept bills/invoices/medical treatment related documents only in
the Insured Person’s name for whom the claim is submitted
2. In the event of a claim lodged under the Policy and the original documents having been
submitted to any other insurer, the Company shall accept the copy of the documents and
claim settlement advice, duly certified by the other insurer subject to satisfaction of the
Company
3. Any delay in notification or submission may be condoned on merit where delay is proved
to be for reasons beyond the control of the Insured Person

8.5 Claim Settlement (provision for Penal Interest)

i. The Company shall settle or reject a claim, as the case may be, within 30 days from the
date of receipt of last necessary document.
ii. In the case of delay in the payment of a claim, the Company shall be liable to pay interest
from the date of receipt of last necessary document to the date of payment of claim at a rate
2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of the
Company, it shall initiate and complete such investigation at the earliest in any case not
later than 30 days from the date of receipt of last necessary document. In such cases, the
Company shall settle the claim within 45 days from the date of receipt of last necessary
document.
iv. In case of delay beyond stipulated 45 days the company shall be liable to pay interest at a
rate 2% above the bank rate from the date of receipt of last necessary document to the date
of payment of claim.

8.6 Services Offered by TPA

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Servicing of claims, i.e., claim admissions and assessments, under this Policy by way of pre-
authorization of cashless treatment or processing of claims other than cashless claims or both,
as per the underlying terms and conditions of the policy.
The services offered by a TPA shall not include
i. Claim settlement and claim rejection;
ii. Any services directly to any insured person or to any other person unless such service is in
accordance with the terms and conditions of the Agreement entered into with the Company.

8.7 Payment of Claim

All claims under the policy shall be payable in Indian currency only.

9. GENERAL TERMS &CONDITIONS

9.1 Disclosure of Information

The Policy shall be void and all premium paid thereon shall be forfeited to the Company in the
event of misrepresentation, mis-description or non-disclosure of any material fact by the
policyholder.

9.2 Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the insured person for the Company
to make any payment for claim(s) arising under the policy.

9.3 Records to be maintained

The Insured Person shall keep an accurate record containing all relevant medical records and
shall allow the Company or its representatives to inspect such records. The Policyholder or
Insured Person shall furnish such information as the Company may require for settlement of
any claim under the Policy, within reasonable time limit and within the time limit specified in
the Policy

9.4 Complete Discharge

Any payment to the policyholder, insured person or his/ her nominees or his/ her legal
representative or assignee or to the Hospital, as the case may be, for any benefit under the
policy shall be a valid discharge towards payment of claim by the Company to the extent of
that amount for the particular claim.

9.5 Notice & Communication

i. Any notice, direction, instruction or any other communication related to the Policy
should be made in writing.
ii. Such communication shall be sent to the address of the Company or through any
other electronic modes specified in the Policy Schedule.
iii. The Company shall communicate to the Insured at the address or through any other
electronic mode mentioned in the schedule.

9.6 Territorial Limit

All medical treatment for the purpose of this insurance will have to be taken in India only.

9.7 Multiple Policies

1. In case of multiple policies taken by an insured during a period from the same or one or
more insurers to indemnify treatment costs, the policyholder shall have the right to
require a settlement of his/her claim in terms of any of his/her policies. In all such cases

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 the insurer if chosen by the policy holder shall be obliged to settle the claim as long as
the claim is within the limits of and according to the terms of the chosen policy.
2. Policyholder having multiple policies shall also have the right to prefer claims under
this policy for the amounts disallowed under any other policy / policies, even if the sum
insured is not exhausted. Then the Insurer(s) shall independently settle the claim subject
to the terms and conditions of this policy.
3. If the amount to be claimed exceeds the sum insured under a single policy, the
policyholder shall have the right to choose insurers from whom he/she wants to claim
the balance amount.
4. Where an insured has policies from more than one insurer to cover the same risk on
indemnity basis, the insured shall only be indemnified the hospitalization costs in
accordance with the terms and conditions of the chosen policy.

9.8 Fraud
If any claim made by the insured person, is in any respect fraudulent, or if any false statement,
or declaration is made or used in support thereof, or if any fraudulent means or devices are
used by the insured person or anyone acting on his/her behalf to obtain any benefit under this
policy, all benefits under this policy shall be forfeited.

Any amount already paid against claims made under the policy which are found fraudulent
later under this policy shall be repaid by all recipient(s)/policyholder(s), who has made that
particular claim, who shall be jointly and severally liable for such repayment.

For the purpose of this clause, the expression "fraud" means any of the following acts
committed by the Insured Person or by his agent or the hospital/doctor/any other party, with
intent to deceive the insurer or to induce the insurer to issue an insurance Policy:
(a) the suggestion, as a fact of that which is not true and which the Insured Person does
not believe to be true;
(b) the active concealment of a fact by the Insured Person having knowledge or belief
of the fact;
(c) any other act fitted to deceive; and
(d) any such act or omission as the law specially declares to be fraudulent

The company shall not repudiate the policy on the ground of fraud, if the insured person /
beneficiary can prove that the misstatement was true to the best of his knowledge and there was
no deliberate intention to suppress the fact or that such mis-statement of or suppression of
material fact are within the knowledge of the insurer.

9.9 Cancellation
The Company may cancel the Policy at any time on grounds of mis-representation, non-
disclosure of material facts, fraud by the Insured Person, by giving 7 days’ written notice.
There would be no refund of premium on cancellation on grounds of mis-representation, non-
disclosure of material facts or fraud.

9.10 Automatic change in Coverage under the policy

The coverage for the Insured Person(s) shall automatically terminate:
In the case of demise of the insured person.However, the cover shall continue for the remaining
Insured Persons till the end of Policy Period. All relevant particulars in respect of such person
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(including his/her relationship with the insured person) must be submitted to the company
along with the application. Provided no claim has been made, and termination takes place on
account of death of the insured person, pro-rata refund of premium of the deceased insured
person for the balance period of the policy will be effective.

9.11 Territorial Jurisdiction

All disputes or differences under or in relation to the interpretation of the terms, conditions,
validity, construct, limitations and/or exclusions contained in the Policy shall be determined by
the Indian court and according to Indian law.

9.12 Arbitration
i. If any dispute or difference shall arise as to the quantum to be paid by the Policy,
(liability being otherwise admitted) such difference shall independently of all other
questions, be referred to the decision of a sole arbitrator to be appointed in writing by
the parties here to or if they cannot agree upon a single arbitrator within thirty days of
any party invoking arbitration, the same shall be referred to a panel of three arbitrators,
comprising two arbitrators, one to be appointed by each of the parties to the
dispute/difference and the third arbitrator to be appointed by such two arbitrators and
arbitration shall be conducted under and in accordance with the provisions of the
Arbitration and Conciliation Act 1996, as amended by Arbitration and Conciliation
(Amendment) Act, 2015 (No. 3 of 2016).
ii. It is clearly agreed and understood that no difference or dispute shall be preferable to
arbitration as herein before provided, if the Company has disputed or not accepted
liability under or in respect of the policy.
iii. It is hereby expressly stipulated and declared that it shall be a condition precedent to
any right of action or suit upon the policy that award by such arbitrator/arbitrators of
the amount of expenses shall be first obtained.

9.13 Endorsements (Changes in Policy)

i. This policy constitutes the complete contract of insurance. This Policy cannot be
modified by anyone (including an insurance agent or broker) except the company.
Any change made by the company shall be evidenced by a written endorsement
signed and stamped.
ii. The policyholder may be changed during the Policy Period only in case of his/her
demise or him/her moving out of India. The new policyholder must be the legal
heir/immediate family member. Such change would be subject to acceptance by the
company and payment of premium (if any).

9.14 Terms and conditions of the Policy

The terms and conditions contained herein and in the Policy Schedule shall be deemed to form
part of the Policy and shall be read together as one document.

9.15 Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose
of payment of claims under the policy in the event of death of the policyholder. Any change of
nomination shall be communicated to the company in writing and such change shall be
effective only when an endorsement on the policy is made. In the event of death of the
policyholder, the Company will pay the nominee {as named in the Policy Schedule/Policy

The Oriental Insurance Company Ltd. Corona Kavach Policy-Oriental Insurance

UIN: OICHLIP21063V012021
Policy
Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to the legal heirs
or legal representatives of the Policyholder whose discharge shall be treated as full and final
discharge of its liability under the Policy.
10. REDRESSAL OF GRIEVANCE

In case of any grievance the insured person may contact the company through

Website: www.orientalinsurance.org.in
Toll free: 1800118485 Or 011- 33208485
E-mail: csd@orientalinsurance.co.in
Fax:
Courier:
Insured person may also approach the grievance cell at any of the company’s branches
with the details of grievance.
If Insured person is not satisfied with the redressal of grievance through one of the
above methods, insured person may contact the grievance officer at:
Customer Service Department
4th Floor, Agarwal House
Asaf Ali Road,
New Delhi-110002.

For updated details of grievance officer, kindly refer the link

https://orientalinsurance.org.in/documents/10182/7605007/List+of+Nodal+Officer+.pdf/992a
7f9b-aef7-5cac-c613-ffc05d578a3e

Grievance may also be lodged at IRDAI Integrated Grievance Management System -

https://igms.irda.gov.in/

Insurance Ombudsman –If Insured person is not satisfied with the redressal of grievance
through above methods, the insured person may also approach the office of Insurance
Ombudsman of the respective area/region for redressal of grievance. The contact details of the
Insurance Ombudsman offices have been provided as Annexure-B

The Oriental Insurance Company Ltd. Corona Kavach Policy-Oriental Insurance

UIN: OICHLIP21063V012021
Policy
 11. TABLE OF BENEFITS
Name Corona Kavach Policy-Oriental Insurance
Product Type Individual/ Floater
Category of
Cover Indemnity/Benefit
Rs 50,000/- (Fifty Thousand) to 5,00,000/- (Five Lakh) (in the multiples of
fifty thousand)
Sum insured
On Individual basis – SI shall apply to each individual family member
On Floater basis – SI shall apply to the entire family
Three and Half Months (3 ½ months), Six and Half Months (6 ½ months),,
Policy Period
Nine and Half Months (9 ½ months) including waiting period.
Policy can be availed by persons between the age of 18 years up to 65 years,
as Proposer. Proposer with higher age can obtain policy for family, without
covering self.
Policy can be availed for Self and the following family members
Eligibility i. Legally wedded spouse.
ii. Parents and Parents-in-law.
iii. Dependent Children (i.e. natural or legally adopted) between the day 1
of age to 25 years. If the child above 18 years of age is financially
independent, he or she shall be ineligible.

Hospitalization Medical Expenses of Hospitalization for Covid for a minimum period of 24

Expenses consecutive hours only shall be admissible
Pre
Hospitalization For 15days prior to the date of hospitalization/home care treatment
Post For 30days from the date of discharge from the hospital/completion of home
Hospitalization care treatment
Hospital Daily Cash: 0.5% of Sum Insured per day subject to maximum of
Sub-limits 15 days in a policy period for every insured member
Home care treatment: Maximum up to 14 days per incident
Medical Expenses incurred for Inpatient Care treatment for Covid under
Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems
AYUSH
of medicines shall be covered upto sum insured during the Policy period as
specified in the policy schedule.
The Company shall indemnify costs of treatment incurred by the Insured
person on availing treatment at home for Covid on Positive diagnosis of
Home Care
Covid in a government authorized diagnostic centre maximum up to 14 days
Treatment
per incident, which in the normal course would require care and treatment at
Expenses
a hospital but is actually taken while confined at home subject to policy
terms and conditions.
15
Page

The Oriental Insurance Company Ltd. Corona Kavach Policy-Oriental Insurance

UIN: OICHLIP21063V012021
Policy
Annexure-A
List I – Items for which coverage is not available in the policy
Sl. Item
No
1 BABY FOOD
2 BABY UTILITIES CHARGES
3 BEAUTY SERVICES
4 BELTS/ BRACES
5 BUDS
6 COLD PACK/HOT PACK
7 CARRY BAGS
8 EMAIL / INTERNET CHARGES
9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL)
10 LEGGINGS
11 LAUNDRY CHARGES
12 MINERAL WATER
13 SANITARY PAD
14 TELEPHONE CHARGES
15 GUEST SERVICES
16 CREPE BANDAGE
17 DIAPER OF ANY TYPE
18 EYELET COLLAR
19 SLINGS
20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED
22 TELEVISION CHARGES
23 SURCHARGES
24 ATTENDANT CHARGES
25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED
CHARGE)
26 BIRTH CERTIFICATE
27 CERTIFICATE CHARGES
28 COURIER CHARGES
29 CONVEYANCE CHARGES
30 MEDICAL CERTIFICATE
31 MEDICAL RECORDS
32 PHOTOCOPIES CHARGES
33 MORTUARY CHARGES
34 WALKING AIDS CHARGES
35 SPIROMETRE
36 STEAM INHALER
37 ARMSLING
38 THERMOMETER
39 CERVICAL COLLAR
40 SPLINT
41 DIABETIC FOOT WEAR
42 KNEE BRACES (LONG/ SHORT/ HINGED)
43 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
44 LUMBO SACRAL BELT
45 NIMBUS BED OR WATER OR AIR BED CHARGES
46 AMBULANCE COLLAR
47 AMBULANCE EQUIPMENT
48 ABDOMINAL BINDER
49 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
50 SUGAR FREE TABLETS
51 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical
pharmaceuticals payable)
52 ECG ELECTRODES
53 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT,
RECOVERY KIT, ETC]
54 KIDNEY TRAY
55 OUNCE GLASS
56 PELVIC TRACTION BELT
57 PAN CAN
58 TROLLY COVER
59 UROMETER, URINE JUG
List II – Items that are to be subsumed into Room Charges
Sl. Item
No
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
2 HAND WASH
3 CRADLE CHARGES
4 COMB
5 EAU-DE-COLOGNE / ROOM FRESHNERS
6 GOWN
7 SLIPPERS
8 TISSUE PAPER
9 TOOTH PASTE
10 TOOTH BRUSH
11 BED PAN
12 FLEXI MASK
13 HAND HOLDER
14 SPUTUM CUP
15 DISINFECTANT LOTIONS
16 LUXURY TAX
17 HVAC
18 HOUSE KEEPING CHARGES
19 AIR CONDITIONER CHARGES
20 IM IV INJECTION CHARGES
21 CLEAN SHEET
22 BLANKET/WARMER BLANKET
23 ADMISSION KIT
24 DIABETIC CHART CHARGES
25 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
26 DISCHARGE PROCEDURE CHARGES
27 DAILY CHART CHARGES
28 ENTRANCE PASS / VISITORS PASS CHARGES
29 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
30 FILE OPENING CHARGES
31 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
32 PATIENT IDENTIFICATION BAND / NAME TAG
33 PULSEOXYMETER CHARGES
List III – Items that are to be subsumed into Procedure Charges
Sl. Item
No.
1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES (for site preparations)
3 EYE PAD
4 EYE SHEILD
5 CAMERA COVER
6 DVD, CD CHARGES
7 GAUSE SOFT
8 GAUZE
9 WARD AND THEATRE BOOKING CHARGES
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
11 MICROSCOPE COVER
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM
17 BOYLES APPARATUS CHARGES
18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE
21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE
List IV – Items that are to be subsumed into costs of treatment
Sl. Item
No.
1 ADMISSION/REGISTRATION CHARGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE
3 URINE CONTAINER
4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES
5 BIPAP MACHINE
6 CPAP/ CAPD EQUIPMENTS
7 INFUSION PUMP– COST
8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET CHARGES
10 HIV KIT
11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT
14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION/STERILLIUM
17 Glucometer& Strips
18 URINE BAG

The contact details of the Insurance Ombudsman offices are as below-
Areas of Jurisdiction
Gujarat , UT of Dadra and Nagar Haveli, Daman and Diu
Karnataka
Madhya Pradesh and Chhattisgarh
Odisha
Punjab , Haryana, Himachal Pradesh, Jammu and Kashmir,
UT of Chandigarh
Tamil Nadu, UT–Pondicherry Town and Karaikal (which
are part of UT of Pondicherry)
Delhi
Assam , Meghalaya, Manipur, Mizoram, Arunachal
Pradesh, Nagaland and Tripura
Andhra Pradesh, Telangana and UT of Yanam – a part of
the UT of Pondicherry
Rajasthan
Annexure-B
Office of the Insurance Ombudsman
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road,
Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@ecoi.co.in
Office of the Insurance Ombudsman,
Jeevan Soudha Building,PID No. 57-27-N-19, Ground Floor, 19/19, 24th
Main Road, JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@ecoi.co.in
Office of the Insurance Ombudsman,
JanakVihar Complex, 2nd Floor,
6, Malviya Nagar, Opp. Airtel Office,
Near New Market,
Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: bimalokpal.bhopal@ecoi.co.in
Office of the Insurance Ombudsman,
62, Forest park,
Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@ecoi.co.in
Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd Floor,
Batra Building, Sector 17 – D,
Chandigarh – 160 017.
Tel.: 0172 - 2706196 / 2706468
Fax: 0172 - 2708274
Email: bimalokpal.chandigarh@ecoi.co.in
Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Anna Salai, Teynampet,
CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
Email: bimalokpal.chennai@ecoi.co.in
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Asaf Ali Road,
New Delhi – 110 002.
Tel.: 011 - 23232481/23213504
Email: bimalokpal.delhi@ecoi.co.in
Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor,
Nr. Panbazar over bridge, S.S. Road,
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
Email: bimalokpal.guwahati@ecoi.co.in
Office of the Insurance Ombudsman,
6-2-46, 1st floor, "Moin Court",
Lane Opp. Saleem Function Palace,
A. C. Guards, Lakdi-Ka-Pool,
Hyderabad - 500 004.
Tel.: 040 - 67504123 / 23312122
Fax: 040 - 23376599
Email: bimalokpal.hyderabad@ecoi.co.in
Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141 - 2740363
 Email: Bimalokpal.jaipur@ecoi.co.in
Kerala , UT of (a) Lakshadweep, (b) Mahe – a part of UT Office of the Insurance Ombudsman,
of Pondicherry 2nd Floor, Pulinat Bldg.,
Opp. Cochin Shipyard, M. G. Road,
Ernakulam-682015.
Tel.: 0484 - 2358759/2359338
Fax: 0484-2359336
Email: bimalokpal.ernakulam@ecoi.co.in
West Bengal, UT of Andaman and Nicobar Islands, Sikkim Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 4th Floor,
4, C.R. Avenue,
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
Email: bimalokpal.kolkata@ecoi.co.in
Districts of Uttar Pradesh : Office of the Insurance Ombudsman,
Laitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, 6th Floor, Jeevan Bhawan, Phase-II,
Allahabad, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Nawal Kishore Road, Hazratganj,
Jaunpur,Varanasi, Gazipur, Jalaun, Kanpur, Lucknow, Lucknow - 226 001.
Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki, Tel.: 0522 - 2231330 / 2231331
Raebareli, Sravasti, Gonda, Faizabad, Amethi, Kaushambi, Fax: 0522 - 2231310
Balrampur, Basti, Ambedkarnagar, Sultanpur, Email: bimalokpal.lucknow@ecoi.co.in
Maharajgang, Santkabirnagar, Azamgarh, Kushinagar,
Gorkhpur, Deoria, Mau, Ghazipur, Chandauli, Ballia,
Sidharathnagar.
Goa, Office of the Insurance Ombudsman,
Mumbai Metropolitan Region 3rd Floor, Jeevan Seva Annexe,
excluding Navi Mumbai & Thane S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052
Email: bimalokpal.mumbai@ecoi.co.in
State of Uttaranchal and the following Districts of Uttar Office of the Insurance Ombudsman,
Pradesh: Bhagwan Sahai Palace
Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, 4th Floor, Main Road,
Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut, Naya Bans, Sector 15,
Moradabad, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Distt: Gautam Buddh Nagar,
Farrukhabad, Firozbad, Gautambodhanagar, Ghaziabad, U.P-201301.
Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj, Tel.: 0120-2514250 / 2514252 / 2514253
Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur. Email: bimalokpal.noida@ecoi.co.in
Bihar, Office of the Insurance Ombudsman,
Jharkhand. 1st Floor,Kalpana Arcade Building,,
Bazar Samiti Road,
Bahadurpur,
Patna 800 006.
Tel.: 0612-2680952
Email: bimalokpal.patna@ecoi.co.in
Maharashtra, Office of the Insurance Ombudsman,
Area of Navi Mumbai and Thane Jeevan Darshan Bldg., 3rd Floor,
excluding Mumbai Metropolitan Region C.T.S. No.s. 195 to 198,
N.C. Kelkar Road, Narayan Peth,
Pune – 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@ecoi.co.in